<form action="<?php echo $this->getFormAction();?>" method="post">
<input type="hidden" name="type" value="3">
<input type="hidden" name="page" value="corporate">
<table id="corporate-left" width="100%">
	<tr class="sel-name">
		<td>
			<select name="title">
				<option value="1"><?php echo $this->__("Mr.");?></option>
				<option value="2"><?php echo $this->__("Mrs.");?></option>
				<option value="3"><?php echo $this->__("Miss");?></option>
			</select>
		</td>
		<td><input type="text" name="first_name" value="<?php echo $this->__("Your name");?>" onfocus="this.value=''"></td>
	</tr>
	<tr>		
		<td colspan="2"><input type="text" name="last_name" value="<?php echo $this->__("Surname");?>" onfocus="this.value=''"></td>
		
	</tr>
	
	<tr>		
		<td colspan="2"><input type="text" name="address" value="<?php echo $this->__("Address");?>" onfocus="this.value=''"></td>
		</tr>
	
	<tr><td colspan="2"><input type="text" name="city" value="<?php echo $this->__("City");?>" onfocus="this.value=''"></td></tr>
	<tr><td colspan="2"><input type="text" name="zip" value="<?php echo $this->__("Zip Code");?>" onfocus="this.value=''"></td></tr>
	<tr><td colspan="2"><select name="country"><option value=""><?php echo $this->__("Country of residence");?></option><?php echo $this->getCountryOptions();?></select></td></tr>
	<tr><td colspan="2"><input type="text" name="country" value="<?php echo $this->__("Company");?>" onfocus="this.value=''"></td></tr>
	<tr><td colspan="2"><input type="text" name="no_of_employees" value="<?php echo $this->__("No. of Employees");?>" onfocus="this.value=''"></td>
</tr>
	<tr><td colspan="2"><input type="text" name="position" value="<?php echo $this->__("Position");?>" onfocus="this.value=''"></td></tr>
	<tr><td colspan="2"><input type="text" name="cif" value="<?php echo $this->__("CIF");?>" onfocus="this.value=''"></td></tr>
	<tr><td colspan="2"><input type="text" name="tel" value="<?php echo $this->__("Contact Telephone");?>" onfocus="this.value=''"></td></tr>
	
	<tr>		
		<td colspan="2"><input type="text" name="email" value="<?php echo $this->__("Email address");?>" onfocus="this.value=''"></td>
	
	</tr>

</table>




<table id="corporate-right" width="100%">
	<tr>
		
		<td>
			<div class="gift_choose">
				<span><?php echo $this->__("For what occasion do you need a gift?");?></span>
				<div class="choose_item"><input type="checkbox" name="gift_feedback[]" value="Christmas">&nbsp;<?php echo $this->__("Christmas");?></div>
				<div class="choose_item"><input type="checkbox" name="gift_feedback[]" value="A congress or event">&nbsp;<?php echo $this->__("A congress or event");?></div>
				<div class="choose_item"><input type="checkbox" name="gift_feedback[]" value="As an incentive for your sales team">&nbsp;<?php echo $this->__("As an incentive for your sales team");?></div>
				<div class="choose_item"><input type="checkbox" name="gift_feedback[]" value="As a thank you">&nbsp;<?php echo $this->__("As a thank you");?></div>
				<div class="choose_item"><input type="checkbox" name="gift_feedback[]" value="Special customer request">&nbsp;<?php echo $this->__("Special customer request");?></div>
				<div class="choose_item"><input type="checkbox" name="gift_feedback[]" value="General enquiries">&nbsp;<?php echo $this->__("General enquiries");?></div>
				<div class="choose_item"><input type="checkbox" name="gift_feedback[]" value="Other">&nbsp;<?php echo $this->__("Other");?></div>
			</div>		
		</td>		
		
		</td>
	</tr>


	<tr>
	<td><textarea name="content" rows="5" cols="50" class="enquiry_text" onfocus="this.value=''"><?php echo $this->__("Comment / Suggestions / Requests");?>
			</textarea></td>

	</tr>
	<tr>		
		<td align="right"><input type="submit" name="submit_button" value="<?php echo $this->__("Submit contact");?>" id="contact_submit"></td>
	
	</tr>	
	
</table>



</form>
